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Teeth Hypersensitivity 1

Introduction:
Teeth hypersensitivity is an exaggerated response to a sensory
stimulus that usually causes no response in normal healthy teeth. As a
source of chronic irritation, teeth hypersensitivity affects eating, drinking,
and breathing. Hypersensitive teeth are characterized by transient pain
in response to evaporative, tactile, thermal, electrical or chemo-osmotic
stimulation of exposed dentin in teeth where no other defects or
pathology exist (9).
Etiologies(causes)
I) Preoperative etiological factors:
a) Bacterial
b) Chemical - Osmotic
c) Mechanical
d) Thermal
e) Idiopathic

II) Post operative (Iatrogenic):


a) Factors related to cavity preparation
b) Factors related to restorative phase and restorations

c) Factors related to vital teeth bleaching.

I) Preoperative etiological factors:


a) Bacterial:
*Dental caries produces different levels of teeth hypersensitivity that
is mainly related to the depth of decay, dentin conductance and Pain
threshold of the patient himself.
Caries in enamel involve no or little hypersensitivity, in dentin is
characteristic to be short and sharp pain arising from exposed dentin in
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response to stimuli, and dull ache pain if pulpal changes occur which
might represent an irreversible pulpitis (21,51).
*Greater degree of sensitivity happens when dental caries passes the
DEJ. as caries penetrates further into the tooth, sensitivity lessens until
pulp becomes involved (31).
*Deeper in dentin and near the pulp, the number of dentinal tubules is
higher, the bigger the diameter of the dentinal tubules, the shorter their
length, the higher the permeability of the dentinal fluids and
consequently the higher the degree of hypersensitivity (49).
b) Chemical-Osmotic:
*Erosion is defined as the dissolution of teeth by acids which are not
of bacterial origin. When an acid or an osmotic agent like sugar
adhere to the margins of leaky restoration or exposed dentin that will
affect the flow of dentinal fluid and result in hypersensitivity.
*Erosion can be of Extrinsic or Intrinsic origin (81,64).
*Extrinsic erosion results of exposure to extrinsic food, fluid or
agents, such as citrus fruits, pickled food, fruit juice, carbonated
drinks, wines, ciders, vitamin C, some mouth rinses with low PH and
bleaching agents especially those delivered in a vacuum formed trays
for In home applications (29,39,3).
*Intrinsic erosion may result from gastric reflux as in Hiatus hernia,
(60)
alcoholism, eating disorders like bulimia nervosa . In case of
intrinsic erosion the palatal aspect of the upper anterior teeth and the
occlusal and buccal surfaces of the lower posterior teeth are primarily
affected (61,7).
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c) Mechanical
i) Attrition:
is defined as wear of teeth at sites of direct contact between teeth.
Attrition is associated with occlusal function and can be aggravated by
habits or parafunctional activities which is known as bruxism (69).

ii) Bruxism:
The aetiology of bruxism is unknown but it could be associated with:
• Sleep disorders as obstructive sleep apnea and Snoring.
• Malocclusion
• High consumption of alcohol and heavy smooking
• Stress, digestive problems.
• Disorders as Huntington and parkinson’s diseases
• Drugs as: MDMA, cocaine
The bruxism results in hypersensitivity to heat and cold, fractured
teeth and fillings, musculofacial pain and headache, stiffness and pain
in the joints and earache.

iii) Abrasion:
It is defined as the wear of teeth caused by objects other than other
teeth such as tooth brush/toothpaste abrasion, scaling and root
planning and pipe smoking (46).

iv) Abfraction:
It is defined as the wear of teeth at the cervical portion as a result of
occlusal loading that leads to cuspal flexure, this in turn results in
compressive and tensile stresses at the cervical fulcrum area of the
Teeth Hypersensitivity 4

teeth with the resultant weakness and gradual loss of the cervical
portion (60).

v) Gingival recession:
It may result from tooth brush abrasion, malocclusion, excessive
brushing and flossing. Gingival recession results in exposure of
cementum which less resistant to abrasion and acids than enamel, that
consequently will lead to exposure of dentin and hypersensitivity (6).

vi) Cracked tooth syndrome:


it is defined as incomplete fracture of the vital teeth, can be involved
in dentin only or extending to the pulp. Cracked tooth syndrome
resulted in Teeth hypersensitivity with biting relieved with releasing
the bite. Might involve severe spontaneous pain in case of pulp
involvement. Can happen in sound teeth especially upper premolars,
or most commonly in teeth that is restored with big restoration or
direct gold (42).

vii) Trauma
Can involve fracture of enamel only with little or no sensitivity,
enamel and dentin with moderate to sharp pain with stimuli typically
evaporative, thermal, mechanical (tactile) or osmotic, pulp
involvement with dull ache spontaneous pain, or fracture of the root
which will result in tenderness to touch or percussion. The trauma
might result in no damage at all but tenderness to touch as a result of
trauma to the periodontal ligament that can subside later (15).
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d) Thermal and idiopathic:


Which can result in reversible hypersensitivity that subside by treating
the exposed dentin and preventing the cause, and irreversible pulpal
damage .

II) Post operative (Iatrogenic):


a) Factors related to cavity preparation: (47)

i) Type of cutting instruments:


Rotary instruments produce more heat generation than the hand
instruments. Dull instruments might require higher pressure for
cutting which will result in more heat generation. Heat can destruct
pulpal tissue, coagulate protoplasm and even burn dentin. Proper
cooling is mandatory with all rotary instruments.

ii) Instrumentation pressure:


Cause heat generation and might cause actual aspiration of
odontoblastic nuclei into the tubules.

iii) Vibration:
Cause a rebound response as a result of using eccentric burs,
which can result in necrotizing effects on dentin.

iv) Dentin Desiccation:


Can result from heating of dentin during cutting, use of chemicals
to sterile the cavity or use of air as a coolant for final cavity toilet.

v) Actual cutting in dentin:


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Every square millimetre of dentin cut exposes 30,000 to 45,000


dentinal tubules with resultant fluid movement in each one of them
stimulating nerve damage.

b) Factors related to restorative phase and restorations

i) Polymerization shrinkage
The polymerization shrinkage results in stresses at the
composite/tooth interface resulting in microleakage, microcracks or
deformation of tooth structure. Microleakage can result in secondry
caries formation and the consequent teeth hypersensitivity.
Stresses are greatest in cavities with high ratio of C factor (ratio of
bonded surfaces to unbonded surfaces), decreasing C factor will
result in decreasing stresses from polymerization shrinkage (20).

ii) Undercured resin


Can result from a light source of inadequate intensity, or not close
enough to the resin, or a light which is attenuated by passage
through tooth structure or restoration. That results in a well cured
surface covering incompletely cured layer, which will result in
marginal fracture, open margin and chemical toxicity from the
monomers or the bonding agent (18,20).

iii) Microleakage
Any restoration though exhibits clinical satisfactory adaptation,
shows some leakage. The ingress of fluids and micro organisms
can be the cause of dentinal hypersensitivity in addition to the fluid
movements within the dentinal tubules (47).

iv) Inadequate liner and/or base


Teeth Hypersensitivity 7

Any metallic restoration conducts thermal changes to the


underlying dentin and pulp which can cause hypersensitivity
specially in the first few days postoperatively. The pain is elicited
after heat or cold application and relieved with removal of the
stimulus. The greater the temperature gradient,the more painful and
lasting the stimulus. The dentin effectiveness as a thermal insulator
depends on its thickness (47).

v) Fractured restoration
Exposes dentin, admits oral fluids and microbes which will cause
recurrent caries and dentin hypersensitivity.
vi) Cracked tooth
Pain on biting and eating citrus fruits, this sharp pain will
disappear when pressure is released. Commonly happens in teeth
with large restoration, direct gold filling with excessive
condensation forces and cast restoration without proper
consideration for cusp protection (42).
vii) Galvanism
When two dissimilar metallic restorations brought into contact
the current will pass between them and a galvanic stimuli will be
generated. Hypersensitivity is usually felt in the tooth containing
the restorative with the lower potential, i.e: Amalgam (49).
The degree of hypersensitivity will depend on some factors as:
The difference in the electrical potential between the dissimilar
metals, the electrical resistance of dentin and soft tissues, presence
of base and its thickness, the current intensity, the pulpal condition
and the patient threshold.

viii) Faulty occlusal and/or proximal relationship


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*Occlusal contact if high will affect the periodontal ligament and


lead to sensitivity with bite and/ or mobility.
*Proximal contact if tight will result in excessice pressure that
might result in pain and interproximal bone resorption and damage
of the supporting structure.
*Proximal contact if light will result in food impaction
interproximally and gingival inflammation, which if neglected will
result in damage of the supporting structure.

ix) Finishing Procedures


*overfinishing of restoration might result in heat generation
which will lead to hypersensitivity.
* finishing of the restoration cervically might lead to scratch or
total loss of the cemetum in this area.
*Over carving of Amalgam restoration or uncovering the exposed
dentin by cement in case of indirect restoration will result in teeth
hypersensitivity.
x) Barodontology
It is the teeth hypersensitivity that occurs with reduced pressure,
which occur during Aviation(in aeroplane). This could be due to
voids under restoration or gases in a non vital pulp.

xi) Gingival reaction to the restorative procedure and restoration


*Retraction cord and chemical tissue packs used before the
elastic impression taking, can result in soft tissue irritation.
*Improperly contoured or overhanging temporary dressing can
result in gingival irritation.
* Overcontoured permanent restorations will contribute to poor
gingival health by preventing through cleaning of the area.
Teeth Hypersensitivity 9

*Undercontoured restorations will contribute to lack of protection


of the gingival crevice and mechanical trauma of the free gingiva.
*Cementing media left in the crevice may cause gingival
irritation that ranges from mild to severe inflammation (47).

xii) Pulpal reaction to the restorative procedure and restoration.


The pulpal reaction to a restorative procedure is difficult to
determine, sometimes even with a conservative cavity preparation,
the pulp experiences a degree of degeneration. Deep restoration
may cause the pulp to devitalize many years later.
A pulp exposure followed by a direct pulp capping might initiate
an immediate hyperemia which can lead to root canal treatment.
Generally if the hypersensitivity remains for several weeks the root
canal treatment is recommended. A direct pulp capping is
considered successful if the tooth is a symptomatic and gives a
positive vitality test from 3-6 months later.

xiii) Local anesthesia


Sometimes soreness occurs at the site of injection as a result of
haematoma and or infection. Beside discoloration the area is
usually tender.

c) Factors related to vital teeth bleaching.

Both office and home bleaching procedures may induce discomfort


in some patients. The principal complaints are mild tooth sensitivity to
temperature changes and local oral mucosal irritation (40).
Bleaching sensitivity is commonly associated with Carbamide
(32)
peroxide vital teeth bleaching due to the by products of 10%
carbamide peroxide readily pass through the enamel and dentin into
Teeth Hypersensitivity 10

the pulp in a matter of minutes. Sensitivity takes the form of reversible


pulpitis caused from the dentin fluid flow and pulpal contact of the
material. Sensitivity can happen in any form of the bleaching agents, it
depends mainly on the peroxide concentration and the patient
threshold.
Theories for Dentin Hypersensitivity (8)
i) Odontoblastic transduction theory
According to this theory, odontoblastic processes are exposed on the
dentin surface and can be excited by a variety of chemical and
mechanical stimuli. As a result such stimulation neurotransmitters are
released and impulses are transmitted towards the nerve endings. The
researches doesn’t support this theory as no neurotransmitters have been
found to be produced or released by odontoblastic processes.
ii) Neural theory
It is an extension of the Odontoblastic transduction theory, this
concept advocates that thermal or mechanical stimuli directly affect
nerve endings within the dentinal tubules through direct communication
with pulpal nerve fibers. This theory is supported by the observation of
presence of unmediated nerve fibers in the outer layer of the root dentin
and the presence of putative neurogenic polypeptides. This theory is
considered with no solid evidence to support it.

iii) Hydrodynamic theory


It is the most accepted theory proposed by Brannstrom et al. The basis
of this theory is the fact that the fluid filled dentinal tubules are open to
the oral cavity at the dentin surface as well as within the pulp. The
hydrodynamic theory postulates that perception of hypersensitivity
occurs as a response to low intensity stimulation of afferent A delta
nerve ends by sudden inward-outward movement of tubular fluid on
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application of non-noxious stimuli to exposed virgin dentin surface.


These nerve fibers interweave with the odontoblasts and the dentinal
tubules along a distance of 100 micrometer from the pulp surface. They
are mylinated have relatively low stimulation threshold, and are poly
modal. They serve as mechanoreceptors for low intensity non-noxious
stimuli.

Natural dentin desensitization (22)


Some natural processes can improve hypersensitivity overtime, even
without treatment intervention. These include sclerosis of dentin,
deposition of secondary and tertiary dentin, creation of a smear layer and
calculus formation on the surface of the dentin.
*Sclerosis of dentin involves deposition of minerals within tubules that
results in a thicker layer of peritubular dentin, this process eventually
results in the tubule becoming smaller in diameter, making it less
permeable and less able to transmit stimuli.
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*Secondary dentin develops after the tooth root is formed, it is secreted


slowly on the floor and roof of the pulp results in decrease in the size of
the pulp chamber.
*Tertiary dentin or the reparative dentin is formed after the exposed
dentin has been traumatized by a stimulus, this natural process decrease
the permeability of dentin.
*The smear layer is described as a combination of organic and
inorganic debris, the smear layer plugs the dentinal tubule orifices with
debris that consists of dental shavings, tissue debris, odontoblastic
processes and microbial elements.
*Calculus formation provides a protective coating to cover dentin from
stimuli. Usually sensitivity ocurrs immediately after removal of heavy
calculus which subside naturally within 2 weeks.

Management of postoperative dentin Hypersensitivity


Diagnosis:Which includes:
History taking, clinical examination and differential diagnosis,
assessment of the etiological factors and management of the
etiological factor after accurate diagnosis

a) History:

*The patient is asked to describe the characteristics of pain as: onset,


duration, stimuli, spontaneity, intensity and factors that relief the
pain.
*After careful listening to the pt, the dentist need to gather the
information related to Subjective information (symptoms) and the
objective information (Signs) through clinical examination.
* Subjective evaluation could be carried out by a verbal rating scale,
which is a 4 scale grading pain as slight, moderate, severe and
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agonizing, by Visual analogue scale is a line of 10cm in length the


extremes of the line represent the limits of pain experienced by the
patient from no pain and till the most sever pain and the McGill
word descriptors by answering a pre prepared questionnaire (44,45).

b) Clinical and Radiographic examination:

*it is the objective evaluation of clinical signs using: (2)


- Mechanical stimulus: Probe, scaler, constant pressure probe
and Yeaple pressure stimulators.
- Chemical (osmotic) stimulus: Sodium chloride, sucrose,
glucose and calcium chloride.
- Electric stimulus: Electrical pulp tester and dental pulp
stethoscope.
- Evaporative test: air blast, Air jet stimulator
- Thermal stimulus: Ethyl chloride, ice stick and heat
thermoelectric devices.
*It involves clinical examination of teeth by percussion, probing,
trans-illumination and other methods to detect the cause of the
problem as caries, fractured restoration, cracked tooth or others.
c) *Radiographic examination to examine the bone, root and

surrounding structure to confirm the diagnosis.


d) Differential diagnosis:
Dentin hypersensitivity is diagnosed by exclusion (33), so all the other
factors should be ruled out. From the diagnosis we can point the
aetiological factor and treat the source of the problem.
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 Minimize preparation trauma


 Maximize dentin seal using dentin bonding agents
 Avoid :
– inadequate isolation
– overetching, dessicating demineralized dentin
– inadequate priming, primer solvent not evaporated
– inadequate adhesive placement, adhesive not photopolymerized
 Ensure temporary crown is well-fitting
 Ensure correct occlusal contacts

Techniques to Reduce Preoperative Hypersensitivity


I) Home care:
Desensitizing toothpastes / dentifrices
Potassium salts
Toothbrush and toothpaste application: Practitioners should educate
patients on how to use dentifrices and monitor their toothbrushing
techniques. Use of a soft or ultrasoft manual toothbrush with soft end
rounded bristles lowers the risk of gingival recession and abrasion of
exposed cementum and dentin. With powered toothbrush less pressure is
required on the teeth, they require a light grasp to remove plaque.
Dentifrices should be applied by toothbrushing. There is no evidence to
suggest that finger application of the paste increases effectiveness. Many
patients habitually rinse their mouths with water after toothbrushing.
Rinsing with water may cause the active agent to be diluted and cleared
from the mouth and, thus, reduce the efficacy of the caries-reducing
effect of fluoride toothpastes. (14)
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Mouthwashes and chewing gums: Studies have found that mouthwashes


(26,57)
containing potassium nitrate and sodium fluoride, potassium citrate
(79) (78)
or sodium fluoride or a mixture of fluorides can reduce Dentine
hypersensitivity.
Dietary Modifications: Controlling the consumption of acidic food and
drinks such as citrus fruits, wine, pickled foods and carbonated
beverages. Avoiding brushing immediately after ingestion of acidic food,
as it may accelerate the combined effect of abrasion and erosion, rinsing
with water is recommended before brushing. Additional
recommendations includes drinking something neutral or alkaline such as
milk or water after consuming an acidic diet, Sipping acidic drinks
through a straw and reducing the quality and frequency of acid intake.
Management of parafunctional habits:
Parafunctional habits can result in bruxism, teeth flexture or abfractions
that lead to hypersensitivity, treating the cause as malocclusion, occlusal
prematuraty or stress is recommended first, then preventing further tooth
structure damage by conservative measures as night guard and fluoride.
If home care fails to reduce Dentine hypersensitivity compared with
baseline levels, the next level of treatment, an in-office method, should be
started.

Ii)In office treatment:


Fluoride: Fluorides such as sodium fluoride and stannous fluoride can
reduce dentin sensitivity. (48) Fluorides decrease the permeability of dentin
in vitro, (30) possibly by precipitation of insoluble calcium fluoride within
the tubules.
Ionto-phoresis: This procedure uses electricity to enhance diffusion of
ions into the tissues. Dental iontophoresis is used most often in
Teeth Hypersensitivity 16

conjunction with fluoride pastes (50) or solutions (68) and reportedly reduces
Dentin hypersensitivity. (68,50)
Potassium nitrate: Potassium nitrate, which usually is applied via a
desensitizing toothpaste, also can reduce dentin sensitivity when applied
(34)
topically in an aqueous solution or an adhesive gel. Potassium ions do
reduce nerve excitability in animal models. (56, 42)
Oxalates: Oxalate products reduce dentin permeability and occlude
(27, 58)
tubules more consistently in laboratory studies than they do in
clinical trials. (54)
Calcium phosphates: Calcium phosphates may reduce dentin sensitivity
effectively. Calcium phosphates occlude dentinal tubules and decrease
dentin permeability. (13)
Orajel Tooth Desensitizer : treats pain from sensitive teeth by blocking
dentinal tubules preventing excitation of the tooth nerve.
NovaMin: is the brand name of a particulate bioactive glass that is used
in dental care products. It consists of 45% SiO2, 24.5% Na2O, 24.5%
CaO and 6% P2O5. it delivers an ionic form of calcium, phosphorus,
silica, and sodium which are necessary for bone and tooth mineralization.
NovaMin can be used an effective, non-toxic alternative to fluoride.
Casein Phosphopeptides: It is a water based topical cream, sugar free
with bioavailable calcium and phosphate, in the form of CPP-ACP
(casein phosphopeptides- amorphous calcium phosphates. Recent studies
reported that it provides extra teeth protection and neutralize acids from
acidogenic bacteria and from other external and internal acid sources.
Adhesives and resins: Because many topical desensitizing agents do not
adhere to the dentin surface, their effects are temporary. Stronger and
more adhesive materials offer improved and longer-lasting
desensitization. In the 1970s,
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Lasers:The effectiveness of lasers for treating dentine hypersensitivity


varies from 5 to 100 percent, depending on the type of laser and the
treatment parameters. (37)